Limited Coverage Drugs - Tenofovir

Generic Name

tenofovir

Strength

300 mg
Form tablet

Special Authority Criteria

Approval Period

Diagnosis of chronic hepatitis B – non-cirrhosis

PLUS

  1. lamivudine resistance (previous use of lamivudine for minimum 3 months)

OR

adefovir-experienced with persistent viremia ANDhistory of lamivudine resistance

AND

  1. Compliant with medication
Indefinite

 

Diagnosis of chronic hepatitis B – with cirrhosis

PLUS

  1. Provide histological or radiological evidence of cirrhosis

OR

Provide other evidence of portal hypertension

PLUS

  1. Lab work required as per the chronic hepatitis B form

Practitioner Exemptions

  • None

Special Notes

  • In exceptional cases, PharmaCare may consider requests for coverage of patients who do not meet the established criteria if the physician provides additional documentation supporting the patient’s specific clinical need. The Hepatitis Drug Benefit Adjudication Advisory Committee reviews exceptional case submissions.

Special Authority Request Form(s)